scholarly journals Preferences on the Timing of Initiating Advance Care Planning and Withdrawing Life-Sustaining Treatment between Terminally-Ill Cancer Patients and Their Main Family Caregivers: A Prospective Study

2020 ◽  
Vol 17 (21) ◽  
pp. 7954
Author(s):  
Cheng-Pei Lin ◽  
Jen-Kuei Peng ◽  
Ping-Jen Chen ◽  
Hsien-Liang Huang ◽  
Su-Hsuan Hsu ◽  
...  
Keyword(s):  
Family Caregivers ◽  
Advance Care Planning ◽  
Medical Decision Making ◽  
Terminally Ill ◽  
Medical Decision ◽  
Care Planning ◽  
Terminally Ill Cancer Patients ◽  
Life Sustaining Treatment ◽  
Advance Care ◽  
A Prospective Study

Background: The Western individualistic understanding of autonomy for advance care planning is considered not to reflect the Asian family-centered approach in medical decision-making. The study aim is to compare preferences on timing for advance care planning initiatives and life-sustaining treatment withdrawal between terminally-ill cancer patients and their family caregivers in Taiwan. Methods: A prospective study using questionnaire survey was conducted with both terminally-ill cancer patient and their family caregiver dyads independently in inpatient and outpatient palliative care settings in a tertiary hospital in Northern Taiwan. Self-reported questionnaire using clinical scenario of incurable lung cancer was employed. Descriptive analysis was used for data analysis. Results: Fifty-four patients and family dyads were recruited from 1 August 2019 to 15 January 2020. Nearly 80% of patients and caregivers agreed that advance care planning should be conducted when the patient was at a non-frail stage of disease. Patients’ frail stage of disease was considered the indicator for life-sustaining treatments withdrawal except for nutrition and fluid supplements, antibiotics or blood transfusions. Patient dyads considered that advance care planning discussions were meaningful without arousing emotional distress. Conclusion: Patient dyads’ preferences on the timing of initiating advance care planning and life-sustaining treatments withdrawal were found to be consistent. Taiwanese people’s medical decision-making is heavily influenced by cultural characteristics including relational autonomy and filial piety. The findings could inform the clinical practice and policy in the wider Asia–Pacific region.

Qualitative themes underlying potentially avoidable terminal oncology ICU hospitalizations.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 101-101
Author(s):  
Robert Michael Daly ◽  
Andrew Hantel ◽  
Blase N. Polite
Keyword(s):  
Decision Making ◽  
Advance Care Planning ◽  
Clinical Management ◽  
Medical Decision Making ◽  
Outpatient Setting ◽  
Medical Decision ◽  
Care Planning ◽  
Theory Approach ◽  
Acute Hospitalization ◽  
Advance Care

101 Background: ICU admissions in the last 30 days of life is a quality measure endorsed by the National Quality Forum. Our prior research has demonstrated that nearly half of terminal oncology ICU hospitalizations are potentially avoidable. Methods: This was a retrospective care series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. Using a standardized assessment tool, an oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months prior to hospitalization until death and made a clinical determination of avoidability. Two investigators, blinded to the specialty of the reviewer, used a grounded theory approach to extract clinical themes associated with avoidability from the reviewers’ assessments. Results: The primary themes for avoidability identified and percent by specialty were as follows: failure to initiate appropriate advance care planning in the outpatient setting (68% oncologists, 55% intensivists, 65% hospitalists), failure to integrate understanding of limited prognosis from underlying cancer within the context of acute hospitalization (23% oncologists, 24% intensivists, 26% hospitalists), failure of clinical management (6% oncologists, 21% intensivists, 6% hospitalists), failure to recognize futility of outside hospital transfer (3% oncologists, 0% intensivists, 0% hospitalists), and failure of care coordination (0% oncologists, 0% intensivists, 3% hospitalists). A failure to educate and integrate surrogates into timely medical decision making was a prominent secondary theme for oncologists (22%), intensivists (18%), and hospitalists (29%). Conclusions: The themes identified suggest potential interventions to prevent avoidable terminal oncology ICU hospitalizations, including improved advance care planning in the outpatient setting, inpatient multidisciplinary communication to gain a better understanding of the patient’s underlying malignancy within the context of the acute hospitalization and prevent failures in clinical management, and better education and integration of surrogates in medical decision making.

73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
R Harwood ◽  
H Enguell ◽  
K Sakuda ◽  
E Lunt ◽  
A Ali
Keyword(s):  
Decision Making ◽  
Advance Care Planning ◽  
Medical Decision Making ◽  
Medical Condition ◽  
Medical Decision ◽  
Care Planning ◽  
Data Set ◽  
Discharge Data ◽  
Advance Care ◽  
Gold Standards

Abstract Introduction Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24 hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP). Methods We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set. We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI). Results Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths. There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP. Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50). There were few interactions with secondary care in the 12 months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12 months prior to death). Conclusions We must consider our discharge processes and medical decision making at the front door. A Prognostic indicator Tool would be useful to focus medical decision making. We must recognise infections as end stage disease in advanced ill health, including advanced frailty. We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.

scholarly journals The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful?

Cancers ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 1977
Author(s):  
Francesca Falzarano ◽  
Holly G. Prigerson ◽  
Paul K. Maciejewski
Keyword(s):  
Cancer Patients ◽  
Family Caregivers ◽  
Advance Care Planning ◽  
Care Planning ◽  
Do Not Resuscitate ◽  
Prospective Longitudinal Study ◽  
Advance Care ◽  
Grief Resolution ◽  
Caregiver Grief ◽  
Prospective Longitudinal

Cancer patients and their family caregivers experience various losses when patients become terminally ill, yet little is known about the grief experienced by patients and caregivers and factors that influence grief as patients approach death. Additionally, few, if any, studies have explored associations between advance care planning (ACP) and grief resolution among cancer patients and caregivers. To fill this knowledge gap, the current study examined changes in grief over time in patients and their family caregivers and whether changes in patient grief are associated with changes in caregiver grief. We also sought to determine how grief changed following the completion of advance directives. The sample included advanced cancer patients and caregivers (n = 98 dyads) from Coping with Cancer III, a federally funded, multi-site prospective longitudinal study of end-stage cancer care. Participants were interviewed at baseline and at follow-up roughly 2 months later. Results suggest synchrony, whereby changes in patient grief were associated with changes in caregiver grief. We also found that patients who completed a living will (LW) experienced increases in grief, while caregivers of patients who completed a do-not-resuscitate (DNR) order experienced reductions in grief, suggesting that ACP may prompt “grief work” in patients while promoting grief resolution in caregivers.

Decision-Making Toolkit

2021 ◽  
pp. 60-76
Author(s):  
Jeffrey D. Myers
Keyword(s):  
Decision Making ◽  
Advance Directives ◽  
Advance Care Planning ◽  
Physician Assistant ◽  
Healthcare Providers ◽  
Terminally Ill ◽  
Decision Makers ◽  
Care Planning ◽  
Collaborative Partnership ◽  
Advance Care

Physician assistant (PA) training is rooted in treating the whole patient and developing a trusting and collaborative partnership with patients and their families. This foundation is critical in the advance care planning (ACP) process for patients who are seriously or terminally ill. Understanding the ACP process, the components and reasons behind them, and the tools for successful discussions and decision-making is a key skill set for all healthcare providers, including PAs. This chapter examines the components of ACP, including advance directives, the POLST paradigm, decision-makers, prognostication, documentation, and legacy planning. ACP is key in capturing what is most important to our patients in terms of their health, their life, and their goals related to both.

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